Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate?
A. "I will cover the catheter so he cannot see it."
"I will cover the catheter so he cannot see it."Explanation: This statement suggests attempting to hide the feeding tube from the client. However, addressing the issue of attempting to remove the feeding tube requires a more comprehensive approach, and simply covering the catheter may not address the root cause.
B. "Let me provide more stimulation in his environment."
"Let me provide more stimulation in his environment."Explanation: This statement suggests increasing environmental stimulation. While environmental interventions can be considered, it's important to address the specific behavior and assess whether increased stimulation is an appropriate and effective intervention. It may not directly address the issue of attempting to remove the feeding tube.
C. "Let's wait until tonight to see if he continues this behavior."
"Let's wait until tonight to see if he continues this behavior." Explanation: This statement suggests a passive approach of waiting to see if the behavior persists. However, if a client is attempting to remove a feeding tube, it's important to address the issue promptly to prevent potential harm or complications. Waiting may not be the most proactive approach in this situation.
D. "I will call the doctor and get the prescription."
"I will call the doctor and get the prescription."Explanation: This is the most appropriate choice. Applying restraints requires a healthcare provider's order. The nurse should communicate with the doctor to discuss the client's behavior, assess the need for restraints, and obtain the necessary prescription if deemed appropriate. This ensures a lawful and ethical approach to using restraints.
This question is an excerpt from Nurse Dive's nursing test bank - ATI LPN Proctored Exam. Take the full exam now
Full Explanation
A. "I will cover the catheter so he cannot see it."
Explanation: This statement suggests attempting to hide the feeding tube from the client. However, addressing the issue of attempting to remove the feeding tube requires a more comprehensive approach, and simply covering the catheter may not address the root cause.
B. "Let me provide more stimulation in his environment."
Explanation: This statement suggests increasing environmental stimulation. While environmental interventions can be considered, it's important to address the specific behavior and assess whether increased stimulation is an appropriate and effective intervention. It may not directly address the issue of attempting to remove the feeding tube.
C. "Let's wait until tonight to see if he continues this behavior."
Explanation: This statement suggests a passive approach of waiting to see if the behavior persists. However, if a client is attempting to remove a feeding tube, it's important to address the issue promptly to prevent potential harm or complications. Waiting may not be the most proactive approach in this situation.
D. "I will call the doctor and get the prescription."
Explanation: This is the most appropriate choice. Applying restraints requires a healthcare provider's order. The nurse should communicate with the doctor to discuss the client's behavior, assess the need for restraints, and obtain the necessary prescription if deemed appropriate. This ensures a lawful and ethical approach to using restraints.
Similar Questions
A nurse is reinforcing teaching with a client who has diabetes mellitus about using a glucometer to monitor her blood glucose. Which of the following actions should the nurse identify as an indication that the client understands the instructions?
A. Uses the ball of a finger as the puncture site
Using the ball of the finger (the fleshy part) is not recommended as it can lead to more pain and discomfort. The side of the fingertip is generally preferred for less discomfort and more accurate results.
B. Avoids using the fingers of her dominant hand as puncture sites.
While it's generally recommended to avoid using the fingers of your dominant hand for frequent blood glucose monitoring, it's not always necessary. The client can still obtain accurate readings from her dominant hand if she rotates puncture sites.
C. Uses the side of a fingertip as the puncture site
Using the side of the fingertip is a recommended practice. The side of the fingertip has fewer nerve endings than the pad of the finger, which helps reduce discomfort. This technique is commonly used for more accurate and less painful blood glucose testing.
D. Avoids using the thumbs as puncture sites
Avoids using the thumbs as puncture sites: Using thumbs as puncture sites is generally avoided because they might have thicker skin and could yield less accurate blood samples. Therefore, avoiding thumbs for blood glucose testing is a good practice.
Full Explanation
A. Using the ball of the finger (the fleshy part) is not recommended as it can lead to more pain and discomfort. The side of the fingertip is generally preferred for less discomfort and more accurate results.
B. Avoids using the fingers of her dominant hand as puncture sites:While it's generally recommended to avoid using the fingers of your dominant hand for frequent blood glucose monitoring, it's not always necessary. The client can still obtain accurate readings from her dominant hand if she rotates puncture sites.
C. Using the side of the fingertip is a recommended practice. The side of the fingertip has fewer nerve endings than the pad of the finger, which helps reduce discomfort. This technique is commonly used for more accurate and less painful blood glucose testing.
D. Avoids using the thumbs as puncture sites:
Using thumbs as puncture sites is generally avoided because they might have thicker skin and could yield less accurate blood samples. Therefore, avoiding thumbs for blood glucose testing is a good practice.
A nurse is assisting with teaching a class about minerals. Which of the following minerals is needed for transport of oxygen?
A. Iron
Iron:Function: Iron is essential for the formation of hemoglobin, a protein in red blood cells that carries oxygen from the lungs to the rest of the body. It is vital for oxygen transport and overall cellular function.Relevance: Iron deficiency can lead to anemia, characterized by reduced oxygen-carrying capacity of the blood, resulting in fatigue, weakness, and other symptoms.
B. Magnesium
Magnesium:Function: Magnesium is involved in various cellular processes, including muscle and nerve function, blood glucose control, and bone health. Relevance: While magnesium has important functions in the body, it is not directly involved in the transport of oxygen like iron.
C. Phosphorus
Phosphorus:Function: Phosphorus is a key component of DNA, RNA, and ATP, playing a role in energy metabolism, bone health, and acid-base balance. Relevance: While important for cellular processes, phosphorus is not specifically linked to the transport of oxygen.
D. Potassium
Potassium:Function: Potassium is crucial for maintaining proper fluid balance, nerve impulses, and muscle contractions.Relevance: Potassium is not directly involved in the transport of oxygen; its primary functions are related to electrolyte balance and cellular activities.
Full Explanation
A. Iron:
Function: Iron is essential for the formation of hemoglobin, a protein in red blood cells that carries oxygen from the lungs to the rest of the body. It is vital for oxygen transport and overall cellular function.
Relevance: Iron deficiency can lead to anemia, characterized by reduced oxygen-carrying capacity of the blood, resulting in fatigue, weakness, and other symptoms.
B. Magnesium:
Function: Magnesium is involved in various cellular processes, including muscle and nerve function, blood glucose control, and bone health.
Relevance: While magnesium has important functions in the body, it is not directly involved in the transport of oxygen like iron.
C. Phosphorus:
Function: Phosphorus is a key component of DNA, RNA, and ATP, playing a role in energy metabolism, bone health, and acid-base balance.
Relevance: While important for cellular processes, phosphorus is not specifically linked to the transport of oxygen.
D. Potassium:
Function: Potassium is crucial for maintaining proper fluid balance, nerve impulses, and muscle contractions.
Relevance: Potassium is not directly involved in the transport of oxygen; its primary functions are related to electrolyte balance and cellular activities.
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?
A. Assist the client to low Fowler's position.
Assist the client to low Fowler's position: Placing the client in a semi-upright or low Fowler's position during and after the feeding helps prevent aspiration and facilitates digestion. This position reduces the risk of regurgitation and reflux.
B. Warm the feeding solution to body temperature.
Warm the feeding solution to body temperature: Ensuring the feeding solution is at room temperature or slightly warmer can enhance the client's comfort and reduce the risk of cramping or discomfort caused by cold fluids.
C. Discard any residual gastric contents.
Discard any residual gastric contents: Before initiating a new feeding, it's essential to check and discard any residual gastric contents from the previous feeding to prevent contamination, ensure accurate measurement, and minimize the risk of bacterial growth.
D. Test the pH of gastric aspirate.
Test the pH of gastric aspirate: Checking the pH of gastric aspirate is an important step to confirm the proper placement of the NG tube in the stomach. Gastric pH is typically acidic (pH less than 5), indicating the correct placement of the tube in the stomach rather than the respiratory tract, where the pH is higher (more alkaline).
Full Explanation
A. Assist the client to low Fowler's position:
Placing the client in a semi-upright or low Fowler's position during and after the feeding helps prevent aspiration and facilitates digestion. This position reduces the risk of regurgitation and reflux.
B. Warm the feeding solution to body temperature:
Ensuring the feeding solution is at room temperature or slightly warmer can enhance the client's comfort and reduce the risk of cramping or discomfort caused by cold fluids.
C. Discard any residual gastric contents:
Before initiating a new feeding, it's essential to check and discard any residual gastric contents from the previous feeding to prevent contamination, ensure accurate measurement, and minimize the risk of bacterial growth.
D. Test the pH of gastric aspirate:
Checking the pH of gastric aspirate is an important step to confirm the proper placement of the NG tube in the stomach. Gastric pH is typically acidic (pH less than 5), indicating the correct placement of the tube in the stomach rather than the respiratory tract, where the pH is higher (more alkaline).